What is shoulder bursitis?

A bursa is essentially small sack or pocket of tissue. It is found in various places of the body. They are found where there is movement of skin over bone or tendon over bone. A bursa acts like small cushion and assists with gliding movements. In the shoulder, a bursa is found between the tendons which elevate the arm below and the bone which forms the roof of the shoulder joint above. This is called the subacromial bursa.

If the bursa becomes inflamed it may cause shoulder pain. Sometimes this can be severe enough to prevent sleep at night. The location of the pain is usually just to the side of the top of the shoulder. It often radiates down the side of the arm. When you try and lift your arm the bursa and underlying tendon can get pinched by the acromion above. This results in a painful arc of movement. This is called shoulder impingement.

What causes shoulder bursitis?

Shoulder bursitis is commonly caused by overuse. This may be due to repetitive overhead activities. An injury or a fall may also cause the problem. Anatomical differences in the shape of the bone plays a key role in determining the development of bursitis. Infection, gout and certain medical conditions such as diabetes and thyroid dysfunction can also play a role.

How do you diagnose shoulder bursitis?

Often shoulder bursitis can be diagnosed clinically. A shoulder surgeon like myself will examine your shoulder completely. The diagnosis is suggested if you have a painful arc when lifting the arm or if you have signs of impingement. To test for impingement the arm is placed in various positions of elevation and rotation. The inflamed bursa will be “pinched” against the acromion and cause pain.

X-ray for shoulder bursitis

And x-ray is invariably taken. The reason for the x-ray is twofold.

1. The first is to exclude other causes of pain is such as osteoarthritis of the shoulder / acromioclavicular joint (ACJ), or calcific tendinitis.
2. The second reason for the x-ray is to analyse the shape of the bones in the shoulder. The acromion, which can be thought of as the roof, is located just above the bursa and tendons. Some individuals have a curvature to this bone and in some people the curvature is quite severe. It can end in a sharp point or hook at the front of the shoulder. Shoulder bursitis can take longer to resolve in these people and there is a higher likelihood that surgery may be required.

Ultrasound for shoulder bursitis

An ultrasound scan is another very useful investigation. An ultrasound scan is a non-invasive and inexpensive scan which makes use of sound waves to form a picture of the various tissues in the shoulder. A large, fluid-filled inflamed bursa, is usually easily identifiable. Sometimes impingement can be seen during the ultrasound scan. The ultrasonographer rotates the arm and looks for areas where the bone is pinching the underlying tendon and bursa.

Another reason to have an ultrasound scan is to rule out a tear of the tendons which elevate and rotate the shoulder (the rotator cuff tendons). If a rotator cuff tear is found during the scan more urgent treatment may be required. (see: Two signs that may mean you have a rotator cuff tear)

How do you treat shoulder bursitis?

The first thing to do is to rest the shoulder adequately. You should stop any activities which are exacerbating the pain. Icing may help occasionally and sometimes anti-inflammatories are prescribed. Physiotherapy may be of use to improve posture and reduce pressure on the inflamed bursa.

As a shoulder surgeon, patients normally present to me for further treatment options once these measures have failed. An injection of cortisone into the inflamed bursa is very often successful. This is often the only treatment required. Cortisone is a steroid medication which acts as a strong, localised anti-inflammatory. Occasionally it may take two or three injections for the bursitis to settle completely.

Surgery for shoulder bursitis

Surgery for shoulder bursitis is considered when these other treatment options have not been successful. As a shoulder surgeon I perform the procedure arthroscopically (minimally invasive or keyhole surgery).

Arthroscopic picture of an acromioplasty

The shoulder operation is performed as a day case procedure which means that you do not have to sleep in hospital. A thorough inspection is made of the shoulder joint to rule out any other abnormalities. The inflamed bursa is then removed. In most instances it is found that the overlying bone (acromion) is pinching or rubbing against the bursa and tendon. This happens usually in the front and side areas. The portion of bone in these parts of the acromion is smoothed off and made flat. This procedure is called an acromioplasty and is performed to increase the space between the bone and the underlying tendon. Although the bursa is removed a new one will eventually grow back in its place.

In summary

Shoulder bursitis is a common cause of shoulder pain. Therefore, if you think you may have bursitis it is recommended that you see a shoulder surgeon to discuss further treatment options. You may need investigations if the pain has lasted more than a couple of weeks and initial treatments such as anti-inflammatories have not helped.

Yours in good health,

Dr Warren Matthee

MB BCh (Wits), MRCS (England), MMed (Ortho Surg), FC Orth (SA)

Orthopaedic Surgeon

admin@drmatthee.com

(011) 304 6784

About the author…

I am an orthopaedic surgeon with a special interest in sports injuries and minimally invasive (arthroscopic) surgery of the knee and shoulder. I treat patients at Waterfall Hospital in Waterfall/Midrand and Morningside Mediclinic in Sandton. Besides these, I also treat patients from other areas as well, including Rosebank, Sunninghill and Fourways.

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The post I have shoulder pain – could this be shoulder bursitis? appeared first on Dr Warren Matthee.

1. Osteoarthritis
2. Meniscal tear
3. Chondromalacia patella..

Osteoarthritis of the right knee; Waterfall Hospital

Osteoarthritis

Osteoarthritis is a degenerative condition of the knee. In layman’s terms it can be thought of as “wear and tear” in the knee joint.The knee consists of three areas or compartments, the medial or inner compartment, the lateral or outer compartment, and the patellofemoral joint (the area under the patella or knee cap). Arthritis in the knee affects one or more of these areas in the knee. The most encountered situation is the development of arthritis in the medial or inner compartment. As the condition progresses there is a gradual narrowing of the joint space on the inner aspect of the knee due to cartilage thinning and a deformity can result which can give the legs a bow-legged appearance. Swelling is often present with arthritis. If the arthritis progresses and becomes unresponsive to non-operative interventions, a total knee replacement may eventually be required.

Arthroscopic picture of a vertical meniscus tear; Waterfall Hospital

Meniscal Tear

The meniscus is a C-shaped cartilage structure in the knee which acts as a “shock absorber”. There are two such structures in the knee, a medial meniscus on the inner side and a lateral meniscus on the outer side. The meniscus can be torn through injury to the knee, but not uncommonly it can also be injured after even minor trauma if the meniscal tissue is weak. Patients complain of pain along the inner side of the knee and there may be associated symptoms such as swelling, clicking and locking. Arthroscopy is often required to treat a meniscus tear.

Chondromalacia patella is usually treated by a muscle strengthening program

Chondromalacia Patella

Chondromalacia patella is an extremely common cause of knee pain. It typically affects younger women but can occur in men and in other age groups as well. The pain is typically located in the front of the knee and is worse when using the stairs or sitting for long periods of time. Patients usually develop a crunching sensation in the knee. Chondromalacia patella literally means softening of the cartilage of the patella and the crunching or crepitus is because of progressive roughness and fissuring of this cartilage. Due to the nerves supplying the knee, the pain from chondromalacia patella can often refer to the inner side of the knee and occasionally causes difficulties in diagnosing the condition. Fortunately surgery is uncommonly needed to treat this condition and strengthening treatment with a physiotherapist or biokineticist is usually all that is needed.

What should do if I have pain on the inner side of the knee?

The above conditions may all present in a similar way, but the treatment for each is usually very different, and ranges from conservative measures such as starting a rehabilitation or strengthening programme, to having major surgery like a total knee replacement. In some instances obtaining an accurate diagnosis may be difficult initially and I would recommend that you see an experienced knee surgeon for a thorough assessment. I see and treat many patients with each of these conditions at Waterfall Hospital in Waterfall/Midrand and at Morningside Clinic in Sandton.

Yours in good health,

Dr Warren Matthee

MB BCh (Wits), MRCS (England), MMed (Ortho Surg), FC Orth (SA)

Orthopaedic Surgeon

admin@drmatthee.com

(011) 304 6784

About the author…

I am an orthopaedic surgeon with a special interest in sports injuries and minimally invasive (arthroscopic) surgery of the knee and shoulder. I treat patients at Waterfall Hospital in Waterfall/Midrand and Morningside Mediclinic in Sandton. Besides these, I also treat patients from other areas as well, including Rosebank, Sunninghill and Fourways.

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If you have had a dislocated shoulder, the question remains whether surgery is needed. There are two broad aspects to shoulder dislocation. The first is treating a dislocated shoulder (this seldom requires surgery). The second is treating a shoulder which was dislocated previously but has already been put back (this often requires surgery). To put things differently once you have had a shoulder dislocation it is highly likely that you will require surgery.

How do you fix a dislocated shoulder?

A dislocated shoulder is an emergency and requires urgent reduction. Reduction means to put the shoulder back into joint. This can sometimes be done immediately after the shoulder has dislocated. This is often seen being performed by professionals on the sports field. Most people however will have the shoulder reduced in the emergency department of a hospital. A muscle relaxant with sedation is usually needed and specific manoeuvres are used to safely relocate the dislocated shoulder.

An examination is performed to ensure that no nerve injury has been sustained during the shoulder dislocation (and before the reduction). An x-ray will usually have been taken before the reduction. This is to ensure that there are no injuries and to confirm the direction of the dislocation. Another x-ray is required afterwards to confirm and document the success of the reduction.

What is the fastest way to heal a dislocated shoulder?

The fastest way to heal a shoulder dislocation (after it has been put back, of course) is a period of rest, followed by physiotherapy. Once the shoulder is reduced, an arm sling is worn for a few weeks. Sometimes a brace which immobilises the shoulder in a certain position is prescribed. This period of rest is necessary to allow the injured tissues to heal. Physiotherapy may then be started to restore range of movement and strength.

Do I need further surgery after a shoulder dislocation, even though the shoulder has been put back?

This is highly likely. A dislocated shoulder usually causes damage to the stabilising structures in the shoulder. This includes a tear of the cartilage (labrum) in the front of the joint. This is called a Bankart tear. Sometimes a small piece of bone is broken off with the cartilage tear. This is then referred to as a bony Bankart lesion. A Bankart tear or lesion predisposes you to having an unstable shoulder.

As you get older, the chances of having an unstable shoulder decrease. Patients in their 20’s and 30’s however, are at high risk for recurrent dislocations and instability. Surgery is therefore recommended for younger patients, even after only one shoulder dislocation.

A complete examination should be performed before the decision is made to operate. There may be clinical features to suggest instability such as the apprehension test and the relocation test. The apprehension test involves placing the arm in a vulnerable position where the shoulder is likely to dislocate. A person who has instability will be apprehensive and tense their muscles. This is a positive test. The relocation test involves applying pressure to the front of the shoulder while doing the apprehension test. If this reduces the apprehension, the test is positive. This strengthens the case to perform an anterior (front) stabilising procedure.

The examination is also necessary to rule out any nerve damage. Not uncommonly, the axillary nerve is injured in a shoulder dislocation. This results in an area of numbness on the outside of the shoulder and weakness of the muscle which helps lift the arm (deltoid).

Surgery for shoulder dislocation

The two commonest procedures performed for a dislocated shoulder are a Bankart repair and a Latarjet procedure.

Bankart repair

The Bankart repair is an arthroscopic operation. This is minimally invasive “keyhole surgery”. This procedure is performed for patients who are involved in non-contact sports. The operation involves stitching the detached cartilage back to the bone and thereby restoring the stability to the shoulder. A bony Bankart procedure is essentially the same operation. The difference is that there is a small piece of bone attached to the torn cartilage. During the cartilage repair the bone is approximated to the site where it broke off to encourage healing. Occasionally, a large fragment of bone may need to be fixed with a small screw.

Latarjet procedure

The Latarjet operation is an open procedure. This means that it is done through a large incision on the front of the shoulder. A small piece of bone from the scapula, (the coracoid process) is cut free. This is transferred to the area of instability on the front of the shoulder socket (glenoid). The coracoid and its tendons are fixed in this area with one or two screws. Some surgeons can perform this procedure arthroscopically, but this is extremely uncommon. The Latarjet procedure is favoured for patients who are involved in contact sports such as rugby. It may also be indicated if a Bankart repair has failed. Some surgeons prefer this as the primary procedure for shoulder dislocations.

There is much debate among shoulder surgeons as to which procedure is better. There is no clear-cut answer. Surgeons like myself who have had extensive training in arthroscopic surgery may favour the Bankart repair. If done correctly if all principles are adhered to this procedure can give excellent results. There is little debate, however, that the Latarjet procedure is better if you are involved in contact sports.

How long does it take to recover from a dislocated shoulder?

If you do not have surgery, then it may take only a few weeks to recover from a dislocated shoulder. Without surgery you may continue to have further dislocations and instability.

After a surgical procedure such as a Bankart repair, the first few weeks are spent in an arm sling protecting the repair. It is recommended that you receive regular physiotherapy to restore range of motion and strength. Typically, weight training is avoided until at least 3 to 4 months after the operation. By six months it is expected that you will have achieved full range of movement and may resume normal sporting activities.

Can a dislocated shoulder heal itself?

Sometimes a dislocated shoulder can spontaneously reduce. The question really is whether the associated cartilage and/or bone injury can heal. This is certainly possible as there are a percentage of patients who do not have any problems after a dislocation. The reasons behind this are multi-factorial, but age is one important consideration. The older you are the less likely you are to experience recurrent dislocations and instability. If the cartilage damage heals in such a way that it provides stability, then you may not have any further dislocations.

In conclusion…

For a traumatic shoulder dislocation, surgery is usually needed. The younger you are the more likely you will be to have instability and recurrent dislocations. Repeated dislocations can damage the cartilage of the shoulder and lead to painful arthritis in later years.

As an orthopaedic surgeon with a special interest in shoulder surgery, I see and treat patients with shoulder dislocations and instability. I treat patients at Waterfall Hospital in Waterfall/Midrand and Morningside Mediclinic in Sandton. I also treat patients from many other areas as well, including Rosebank, Sunninghill and Fourways.

Yours in good health,

Dr Warren Matthee

MB BCh (Wits), MRCS (England), MMed (Ortho Surg), FC Orth (SA)

Orthopaedic Surgeon

admin@drmatthee.com

(011) 304 6784

The post Do I need surgery for a dislocated shoulder? appeared first on Dr Warren Matthee.

A distal biceps tendon tear is a common injury among bodybuilders. It appears to have increased in frequency in recent years. While improvements in diagnostic imaging may have played a role, I suspect that it has more to do with an increase in supplement use and lifting heavier weights as a result.

The biceps is an interesting muscle in that it attaches to bony surfaces by means of tendons on both sides of the muscle. It is possible for the biceps tendon to be torn from the upper attachment. This is a proximal biceps tendon tear and generally occurs in older individuals who have a degenerative tendon. This condition will not be discussed further here – I will focus on biceps tears involving the lower attachment to the bone in the forearm (the radius).

Contraction of the biceps muscle causes two movements of the forearm. The most obvious is bending or flexion at the elbow. The other important movement is supination. This is a rotatory movement of the forearm where the hand turns to the palm-up position, like when one is holding a bowl of soup.

What causes a distal biceps tendon tear?

A distal biceps tendon tear usually occurs because of trauma in a young, active individual. It is a common injury seen in bodybuilders who lift extremely heavy weights. It may also occur in the casual gym-goer and in people engaged in other activities. I recall one patient describing that he sustained the injury while trying to stop a small boat sliding off the roof-racks of his car. Another patient was a rock climber who sustained the injury while hanging from a rock with one hand during a climb. The common mechanism of injury is that there is a forced extension of the forearm while the biceps is contracting strongly.

Although the injury is called a tear, it is an avulsion. This means that the tendon tears away from the bone at its point of attachment. The result is that the entire length of the tendon is usually intact and can be reattached to the bone.

How is a distal biceps tendon tear diagnosed?

In many instances the injury is obvious, and the person will tell you that they “felt the biceps tendon go”. There is often bruising on the inside of the elbow and there is weakness with flexion and supination, especially against resistance. The “hook test” may be positive. In this test the examiner tries to hook underneath the biceps tendon with his or her index finger from the side of the elbow. If there is a complete rupture of the biceps tendon the examiner may not be able to do this. Another sign to look out for is the “Popeye deformity”. With a ruptured biceps tendon, when one tries to flex the arm the biceps rolls into a ball, causing a visible cosmetic deformity, likened to the appearance of Popeye’s bicep muscle.

Often the history of having felt a “pop” in the elbow along with a careful clinical examination will be all that is needed to diagnose a distal biceps tendon tear. If there is any doubt, an ultrasound or MRI scan may be obtained.

What are the treatment options for a distal biceps tendon tear?

A complete distal biceps tendon tear usually does not heal back to the bone. With time the tendon may become shortened and degenerate. There are two treatment options. One option is to do nothing and the second is to have the tendon repaired surgically. There are other muscles in the upper limb which can take over the functions of flexion and supination. With physiotherapy and a good strengthening and rehabilitation programme, these deficits may be overcome to some degree in those who choose not to have surgery. There will, however, usually be a degree of residual weakness in the arm. This may not be noticeable by some patients but may cause significant impairment in others who rely on full supination strength (e.g. using a screwdriver, turning a doorknob).

Another important factor to consider is cosmesis. Some individuals will accept the Popeye cosmetic deformity. Most individuals, however, who have this injury are younger, image-conscious males who would like to have the normal contour of their biceps muscle restored.

Surgery is therefore indicated for those who require maximal restoration of strength and function in the arm and for those who wish to restore cosmesis. One of the most important factors is that if surgery is chosen it should be performed as soon as possible. Early surgery is associated with the best outcomes. The procedure does not need to be done as an emergency but should be performed within the first two weeks. After six weeks a repair may be not possible as the tendon begins to shorten and become degenerate. An attempted repair after six weeks has a high failure rate.

What does surgery for a distal biceps tendon tear involve?

Surgery may be done on an outpatient basis which means you do not have to spend the night in hospital. The procedure involves making a small incision on the upper end of the forearm, through which the end of the biceps tendon can be retrieved (one incision procedure). Not uncommonly, the tendon rolls up into a little ball or retracts slightly, in which case it must be retrieved through a separate incision higher up over the lower end of the arm (two incision procedure).

There are different techniques of fixing the tendon back to the bone. One technique involves using an interference screw to secure the tendon into the bone. My preferred technique is the suspensory technique. After tendon is retrieved a small metal button is stitched to the end of it with strong, non-dissolvable stitches. A small hole is drilled through the bone where the tendon pulled off. The surrounding bony surface is roughened a bit to encourage healing of tendon to bone. The metal button attached to the end of the tendon is then threaded through the drill hole to the other side of the bone and then flipped to anchor the tendon securely back down to its bony point of attachment.

Intra-operative X-ray of the flipped metal button anchoring the biceps tendon through a hole drilled in the radius

After the operation, the arm is usually immobilised for a week or two and a sling is worn for a further four weeks. Thereafter one may begin to use the arm normally but lifting any weight is prohibited for at least 4 to 6 months.

Are there any risks associated with surgery?

The surgery generally successful but is not without potential risks. The main areas of concern are injury to blood vessels and nerves in the surrounding area. A branch of the radial nerve is close to the operative field and injury to this nerve may result in weakness or even paralysis of wrist extension. Fortunately, this does not occur commonly. There is a small risk of fracture, but again this is quite rare. If the repair fails, it is usually because of a delay in treatment.

In conclusion…

A distal biceps tendon tear is usually an obvious injury, but in cases where there is any doubt an assessment by a specialist orthopaedic surgeon is needed. Occasionally further investigation such as ultrasound or MRI scan are required in doubtful situations. Surgery is recommended to restore maximal strength and cosmesis. If surgery is considered it should be performed early. Delays in diagnosis and treatment can lead to disappointing results. Many patients who decide against surgery function well but are left with a cosmetic deformity and may have residual weakness of flexion and supination. For further information read: Distal Biceps Tendon Repair.

Yours in good health,

Dr Warren Matthee

MB BCh (Wits), MRCS (England), MMed (Ortho Surg), FC Orth (SA)

Orthopaedic Surgeon

admin@drmatthee.com

(011) 304 6784

About the author…

I am an orthopaedic surgeon with a special interest in sports injuries and minimally invasive (arthroscopic) surgery of the knee and shoulder. I treat patients at Waterfall Hospital in Waterfall/Midrand and Morningside Mediclinic in Sandton. Besides these, I also treat patients from other areas as well, including Rosebank, Sunninghill and Fourways.

Get in Touch

Please use the form below to get in touch with Dr Matthee’s rooms.

The post The distal biceps tendon tear – to fix or not to fix? appeared first on Dr Warren Matthee.

A tennis elbow is a common cause of elbow pain, especially in the 30 – 50 year-old age group. The pain is usually felt on the outer aspect of the elbow and can radiate to the forearm as well. It is usually worse when trying to grip something or when lifting something heavy. A simple task like turning a doorknob may cause discomfort. It may start as a pain which can easily be ignored but can progress to a situation where there is a constant ache which interferes with sleep and daily activities.

What causes tennis elbow?

The medical term for tennis elbow is lateral epicondylitis. At the lower end of the arm (humerus) there is a bony prominence called the lateral epicondyle. This is the attachment point of the tendon of a group of muscles which control extension of the wrist. The pain from a tennis elbow originates at this point of attachment. It is thought that due to repetitive injury small micro-tears develop in the structure of the tendon. This may result in localised inflammation and eventually causes a breakdown of the normal tendon structure.

How do you treat tennis elbow?

Non-surgical treatment

The treatment of tennis elbow begins with simple measures like avoiding the activity which may have caused the problem in the first place. Simple rest may be the only treatment that is needed. In some instances, an anti-inflammatory may be useful. A good recommendation is to stretch out the tendon. The best way to do this is to grab the fingers (especially the index and middle fingers) on the affected side with your other hand and then bend the hand inwards at the wrist (flexion), while keeping the elbow straight. An even better stretch can be obtained if you do this manoeuvre behind your back.

A tennis elbow brace may be useful, especially in the early stages. The brace is basically a strap which is applied around the upper part of the forearm. There is a small cushion which must be positioned over the bulk of the muscle on the back of the forearm. The idea is that light pressure on this area will take tension off the tendon attachment and promote healing and resolution of symptoms.

Injections

I normally see people with established tennis elbow who have already tried some of these interventions and are still having pain. My preferred treatment at this stage is a cortisone injection into the tendon. It’s not as painful as it sounds 😉. It is done in the office and takes just a few minutes. Cortisone acts as a powerful local anti-inflammatory but the injection also causes a small amount of  bleeding in the tendon, and this helps stimulate a healing response. Platelet injections and shock wave therapy can also be tried.

An injection of cortisone is usually quite effective and if the symptoms do not settle completely then a second or third injection may be required. It is not recommended to have more than two or three injections as this is unlikely to be of benefit and may, in fact, cause weakening of the tendon. For situations where conservative treatment has failed surgery is indicated.

Surgical treatment

Surgery for a tennis elbow is a simple procedure which involves removal of diseased portions of the affected tendon (debridement of the tendon). This is done as an outpatient procedure which means you do not have to spend the night in hospital. The procedure is performed through a small incision, 2 or 3 cm long. This is located over the outer aspect of the elbow.

The degenerative portion of the tendon is identified and is excised. Often there is a small bony prominence at the site of degeneration, and this is also removed. The remaining healthy tendon is repaired and the elbow is immobilised in a splint for a week or two. After this period, you may begin using your arm normally although you should avoid picking up or lifting heavy objects. It is possible to get back to work quite quickly after this procedure, but it may take up to 3 months before you have complete resolution of all your symptoms.

In conclusion

Tennis elbow is the commonest causes of elbow pain and can be easily treated. In most instances surgery is not needed but if it is it can be done successfully as an outpatient procedure.

Yours in good health,

Dr Warren Matthee

MB BCh (Wits), MRCS (England), MMed (Ortho Surg), FC Orth (SA)

Orthopaedic Surgeon

admin@drmatthee.com

(011) 304 6784

About the author…

I am an orthopaedic surgeon with a special interest in sports injuries and minimally invasive (arthroscopic) surgery of the knee and shoulder. I treat patients at Waterfall Hospital in Waterfall/Midrand and Morningside Mediclinic in Sandton. Besides these, I also treat patients from other areas as well, including Rosebank, Sunninghill and Fourways.

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Trigger finger is a painful condition of the fingers which can cause the finger to become locked. This means it may be possible to bend the finger but the finger then gets stuck in the bent position. Sometimes the other hand is needed to straighten the finger. In the most severe cases the finger may be unable to straighten at all (locked). The condition also affects the thumb and is then called a trigger thumb. The thumb and ring fingers are most commonly affected digits. More that one finger can be affected at the same time.

The most common complaint is that of pain in the palm of the hand when bending and straightening the finger. This may progress to the clicking, catching or locking as described. With time a mobile, painful nodule may be felt in the palm as the finger moves.

What is the cause of a trigger finger?

A trigger finger commonly occurs in people who have arthritis. There is also an association with diabetes and rheumatoid arthritis. It can sometimes occur after using the hand and fingers forcefully for a period of time. Sometimes the reason it occurs is not clear.

Bending of the fingers is controlled by flexor tendons in the hand. For the tendons to glide freely they are covered by a lining called the tendon sheath. To prevent the tendons from bow-stringing or moving out of position, they are held in place by several pulleys. These are made of strong fibrous tissue.

The problem occurs at the level of the A1 pulley. The A1 pulley is the first pulley which stabilises the tendon. It is located on the palm side of the hand, just before the start of the finger. With a trigger finger the lining of the tendon sheath becomes inflamed. This makes it difficult to pass through the A1 pulley. Bending and straightening of the finger will therefore cause pain and further inflammation.

What will happen if a trigger finger is not treated?

With time a small nodule can develop on the tendon. This can increase in size and worsen the problem. As the condition gets worse the patient can feel a catching or clicking sensation. The finger begins to lock. At this stage it is still possible to straighten the finger, sometimes using other hand. In the most severe form the finger gets stuck in the bent position and cannot be straightened.

Can a trigger finger heal on its own?

A trigger finger may heal on its own, especially if caused by a strenuous activity involving the hands and fingers. With rest, splinting and anti-inflammatories, the inflammation may resolve. If there is arthritis or rheumatoid arthritis it is less likely to heal its own.

What is the best thing to do for a trigger finger?

Initial treatment consists of rest and anti-inflammatories. A splint may be tried to immobilise the finger and reduce inflammation. If this does not help a cortisone injection may be beneficial. Cortisone is a strong anti-inflammatory and this is injected around the tendon sheath. This reduces inflammation and allows the tendon to glide freely without causing catching or locking.

Sometimes the triggering may resolve only to occur again after a few weeks or months. Two or three cortisone injections may be given. If the problem persists then surgery is considered.

What does surgery involve?

Surgery is a simple procedure which is done on an outpatient basis. This means you do not have to spend the night in hospital. The operation is done under local anaesthetic and you will not feel anything. You also given a light sedation to allow you to sleep during the procedure, and you will not remember anything of the operation.

The surgery involves releasing (cutting through) the A1 pulley. There are various techniques – my preferred approach is to perform a small “open procedure”. This involves making a small cut on the skin. The incision is made on the palm of the hand just before the start finger. The A1 pulley is located and released. Any excessive inflammatory tissue can be removed.

Trigger finger sometimes occurs in patients with carpal tunnel syndrome. A trigger finger release and a carpal tunnel release can be performed at the same time (read: Performing surgery for carpal tunnel syndrome).

Other methods involve cutting the pulley through the skin using a needle. As this is not done under direct vision, there is an increased risk of incomplete release and of damage to surrounding nerves.

How long does it take to recover from surgery ?

After the operation the skin is closed with two or three small nylon structures. These are removed 10 days after the surgery. No splint is used, and movement of the finger is encouraged straight away. After successful surgery there is an immediate resolution of the locking and catching. Residual swelling and inflammation may take many weeks to resolve, however.

Yours in good health,

Dr Warren Matthee

MB BCh (Wits), MRCS (England), MMed (Ortho Surg), FC Orth (SA)

Orthopaedic Surgeon

admin@drmatthee.com

(011) 304 6784

About the author…

I am an orthopaedic surgeon with a special interest in sports injuries and minimally invasive (arthroscopic) surgery of the knee and shoulder. I treat patients at Waterfall Hospital in Waterfall/Midrand and Morningside Mediclinic in Sandton. Besides these, I also treat patients from other areas as well, including Rosebank, Sunninghill and Fourways.

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The post What is a trigger finger, and how is it treated? appeared first on Dr Warren Matthee.

Many years ago, after having just started out in private practice, a gentleman came to see me with a complaint of “pins and needles” in his right hand. He hailed from KZN and mentioned that he enjoyed a good curry. I will call him Mr A. I examined him and confirmed that he had carpal tunnel syndrome, and that he needed to have surgery. He agreed and had the procedure was performed a week or two later.

The surgery went really well, and I carefully stitched the wound on the palm of his hand closed. I thought I had done a very good job. As usual I covered the wound with a plaster, and a temporary splint was secured to the hand and forearm with a wool and bandage dressing. I normally ask patients to see me ten days after the surgery to do a wound inspection and to remove the stitches. They will not have taken the dressing or splint off and the procedure is like unwrapping a present on Christmas morning. You hope for a pleasant surprise.

Instead of the “oohs” and “aahs” that I was expecting, when I removed all the dressings Mr A looked down at his hand…and said nothing. I glanced down. It was not very pretty. Despite what I thought had been meticulous technique, the stitching had left a bit to be desired. I would like to be clear here: the wound had healed just fine and there were no complications, but it did look as if he had been lightly savaged by a small dog. Perhaps I am being a bit hard on myself here. Anyway, I reassured him that his wound would look better with time (it would) and that after a few months his scar would be virtually invisible (it was). There was an uncertain laugh; he thanked me, paid his account, and left. My confidence had been dented, and I wondered if I would ever see him again.

Well blow me down if he did not come striding purposefully back into my consulting room six months later. I nervously enquired as to the nature of his visit, and he informed me that he had developed carpal tunnel syndrome in the other hand now, and wanted to have surgery on this hand too. And who would I be to deny such a request? He was booked for the procedure the following week, and it went well. As you can imagine I paid particular attention to the suturing part at the end (not that I didn’t on round one, mind you).

Ten days later, Mr A was in my office for his wound check. I put on a brave face, but I admit that a small- to medium-sized bead of sweat had developed on my forehead as I began unwrapping his bandages. I removed the plaster…Mr A slowly brought both hands together and studied his palms for what seemed like an eternity. He finally looked up, grinning from ear to ear. He patted me on the shoulder, and in that unmistakable accent said: “Getting better hey, Doc?” 🙈😅😂

Yours in good health,

Dr Warren Matthee

MB BCh (Wits), MRCS (England), MMed (Ortho Surg), FC Orth (SA)

Orthopaedic Surgeon

admin@drmatthee.com

(011) 304 6784

About the author…

I am an orthopaedic surgeon with a special interest in sports injuries and minimally invasive (arthroscopic) surgery of the knee and shoulder. I treat patients at Waterfall Hospital in Waterfall/Midrand and Morningside Mediclinic in Sandton. Besides these, I also treat patients from other areas as well, including Rosebank, Sunninghill and Fourways.

Get in Touch

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One of the routine questions I ask patients who see me for a knee problem is if they have noticed any swelling. It surprises me how many people say no, and when I examine them I discover a large swelling in the knee. Knee swelling is not normal. The nature of the swelling gives valuable clues as to the cause and subsequent treatment. I find it useful to divide knee swelling into two groups: swelling inside the knee joint and swelling outside the knee joint.

Knee swelling inside the joint

The knee joint has a normal amount of fluid in it. This is called synovial fluid, It assists with lubrication and nourishment of cartilage. A normal amount of synovial fluid does not cause swelling of the knee and will not be detected as swelling during a routine examination.

Synovial fluid is produced by the inner lining of the knee joint (synovium). The synovium may produce excessive fluid as a result of irritation or inflammation. It is thought that this fluid is produced as a protective measure. The accumulation of fluid in the joint will result in swelling, called an effusion. This may be a small enough to be detected only by the most experienced examiner, or it may be big enough to be seen by everyone in the room.

The synovium itself may cause swelling if it is inflamed and thickened (synovitis). There will usually be some fluid associated with this type of swelling.

Besides normal synovial fluid, blood which accumulates in the joint can also result in swelling. This is seen in conditions such as haemophilia and obviously in acute knee injuries. It is also seen after surgery. I will not discuss these conditions here.

There are many potential causes for a swelling inside the knee joint. Instead of giving you an exhaustive list I would prefer to tell you about some of the common conditions I see daily.

Chondromalacia patella

I really dislike this term, but as it is a common condition I find myself using it often. It is one of the most common causes of anterior knee pain (pain in the front of the knee). It is sometimes called “runners knee” for obvious reasons. I sometimes refer to it as “back ache of the knee”. The term chondromalacia patella means “softening of the cartilage underneath the kneecap” or patella. It usually arises due to long-standing muscle imbalance and mal-tracking issues of the patella. Initially the cartilage underneath the patella become soft. This may progress to fissuring and the cartilage surface becomes rough. This causes a crunching noise in the knee called crepitus. The symptoms are typically worse when using stairs.

Swelling is usually associated with more severe cases where there is significant crepitus and fissuring.

The good news is that this condition does not normally require surgery. It normally responds to a good rehabilitation programme, focusing on core muscle strengthening exercises and strengthening of the quadriceps muscle.

Meniscal tears

An arthroscopic view of a torn meniscal cartilage in the knee

The meniscus is a C-shaped cartilage structure in the knee. There is a medial and a lateral meniscus in each knee. They are like cushions or “shock absorbers”, and also assist with stability and proprioception (position sense). A tear in the meniscus can result in pain along the sides of the joint, clicking, and sometimes locking. Often, however, it is the finding of mild swelling in association with these features that leads me to the diagnosis. A meniscal tear is usually treated surgically by arthroscopy or minimally invasive surgery unless there is significant arthritis in the joint already (read: Three signs that you may have a meniscus tear).

Arthritis

Arthritis is another common cause of knee swelling. There are different types of arthritis which can cause any pain and swelling. The commonest type that I encounter is osteoarthritis. Osteoarthritis is a condition where the normal cartilage in the knee is worn away through wear and tear. In the most severe form the cartilage may be worn right down to the level of the bone. The synovium may become inflamed and produce increased amounts of synovial fluid as described. This will result in an effusion (fluid in the joint). Osteoarthritis is generally seen in older age groups, but may develop in younger people, especially if the knee has had significant trauma.

An inflammatory arthritis such as rheumatoid arthritis will also cause swelling of the knee. Swelling may be the first feature of these conditions.

The treatment of osteoarthritis begins with lifestyle modification, and the use of anti-inflammatories and physiotherapy. Steroid (or other) injections into the joint may be required for more advanced cases. Someone with arthritis who does not respond to these interventions may need a total knee replacement.

Baker’s cyst

A Baker’s cyst is a swelling felt at the back of the knee. It is extremely common. It is caused by fluid in the joint which puts pressure on a weak area in the back of the knee. This causes a bulging of the joint capsule in this area. It is no different to the swelling caused by arthritis – they are one and the same. The fluid is not usually drained from a Baker’s cyst just for the sake of draining the fluid as it will simply re-accumulate. The best treatment of a Baker’s cyst is to treat the underlying cause, which is the arthritis (see above).

Knee swelling outside the joint

There are conditions which can cause knee swelling which do not involve an accumulation of fluid inside the joint itself. This kind of swelling is usually related to a specific area of the knee which makes diagnosis easier.

Bursitis

A bursa is a pocket or sack of tissue which normally has a small amount of fluid in it. They are found throughout the body, especially where the skin moves over a prominent bony area, such as the knee and elbow. They assist with gliding movements of the skin over the bone. There are three bursas in the front of the knee. The prepatellar bursa (in front of the patella); the suprapatellar bursa (above the patella); and the infrapatella bursa below the patella.

Normally you cannot feel a bursa through the skin. If it becomes inflamed or irritated it may fill with fluid and cause a lump. This may happen because of trauma such as a knock to the knee. It may also occur as a result of a repetitive activity. Another name for a prepatellar bursitis is “housemaid’s knee”, supposedly named after a housemaid who develops this swelling due to long hours spent on her knees scrubbing floors. Another name for infrapatellar bursitis is the “clergyman’s knee” – the way a clergyman would kneel to pray would put pressure on the infrapatella bursa.

Bursitis may be treated by anti-inflammatories or cortisone injection. Occasionally a compression brace may help. If the bursal swelling becomes established it may form a thick wall and become a large lump which swells repeatedly every time the knee takes a knock. These are best excised.

Sometimes a bursal swelling can become infected or an infection can result in a bursitis. These should be treated with antibiotics and may require surgical drainage if the infection is severe.

Popliteal aneurysm

An aneurysm is an abnormal swelling in an artery. The major artery which courses down the back of your knee is called the popliteal artery. A swelling or dilatation of this blood vessel is called a popliteal aneurysm. It can be confused with a Baker’s cyst. This aneurysm is outside the knee joint, however, and it is pulsatile. It goes without saying that an attempt to drain this kind of swelling with a needle should NOT be attempted. Popliteal aneurysms may become large and can cause blood clots which can compromise the blood supply to the foot. They are best assessed and treated by a vascular surgeon.

And Gout?

Oh, yes…never forget about gout. I nearly did, which is why it is last on the list.  Gout is a common condition where crystals of uric acid accumulate in a joint. It can result in sudden attacks of pain and swelling. The pain can be quite severe, and sufferers say that it is even too painful to have a bedsheet resting on the joint. In the long term, uncontrolled gout can cause chalky white deposits in tissues. Gout has a tendency to invade through tissue planes and can affect the knee both inside and outside the joint.

Gout can mimic or be found in addition to many of the conditions listed above. The focus of treating gout is to control the body’s uric acid levels through diet, lifestyle modification and/or medication. Gout commonly causes bursitis as described above, and may require surgery. Surgery may also be needed if long-standing gout has resulted in an arthritic knee or a meniscal tear.

There are other causes of knee swelling, both inside and outside the joint. Tumours and rare conditions of the synovial lining come to mind. Fortunately these are not seen commonly and won’t be discussed further.

In conclusion…

A swollen knee is not normal, and should always be investigated properly to establish the cause and to rule out a serious condition which may require surgery.

Yours in good health,

Dr Warren Matthee

MB BCh (Wits), MRCS (England), MMed (Ortho Surg), FC Orth (SA)

Orthopaedic Surgeon

admin@drmatthee.com

(011) 304 6784

About the author…

I am an orthopaedic surgeon with a special interest in sports injuries and minimally invasive (arthroscopic) surgery of the knee and shoulder. I treat patients at Waterfall Hospital in Waterfall/Midrand and Morningside Mediclinic in Sandton. Besides these, I also treat patients from other areas as well, including Rosebank, Sunninghill and Fourways.

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What causes De Quervain’s synovitis?

The pain of De Quervain’s synovitis is caused by inflamed tendons which move the thumb. These tendons pass through a very tight compartment in the wrist. The inflamed sheath which surrounds the tendon causes pain as it moves through the tight compartment when the thumb is moved.

De Quervain’s synovitis has many other names. Is sometimes referred to as radial styloiditis or stenosing tenosynovitis of the wrist. It usually affects women in their 30’s and 40’s. Men may also have the condition. It is commonly seen in pregnant woman. It is also seen in women with young children who are constantly picking up their young ones.

Sometimes the cause is not known. In other instances it is usually related to overuse. It can be caused by doing an activity that you are not accustomed to. This can be pruning rose bushes, for example. Pregnancy is a contributing factor as the body retains fluid. Sometimes a traumatic event can trigger the symptoms.

The pain is located over an area on the side of the wrist called the radial styloid. A firm press on this area will normally cause discomfort. A fairly sensitive test is called the Finkelstein test. In this test the examiner grasps the affected thumb (with the hand in the shaking position), and gently but briskly pulls the hand downwards towards the floor. This usually causes a sharp pain in the affected area.

Treatment

Initial treatment of De Quervain’s synovitis includes rest and anti-inflammatories. Occasionally a splint is used which immobilises the thumb. This is called thumb spica splint. If this does not help then the usual course of action is to inject cortisone around the inflamed tendon. A cortisone injection often cures the problem but if it does not then a surgical release is recommended.

Surgery

Surgery for a De Quervain’s synovitis is a minor operation. It is a day-case procedure. This means that you do not have to sleep in hospital. It is normally done in the safe and controlled environment of the operating theatre and is usually performed under local anaesthetic. In addition, a sedative is given by the anaesthetist. This allows you to sleep during the procedure. With this combination you will not feel or remember anything of the procedure.

The procedure

A small incision is made over the thumb-side of the wrist. It is important to find and protect a nerve which runs across the inflamed tendons. Injury to this nerve may cause pain over the surgical site as well as pain and numbness on the back of the hand. The tight sheath covering the inflamed tendons is then cut to release the tendons. Often several accessory compartments and/or extra tendons are discovered. This is an area of the body where there anatomical variations are commonly found. These compartments must all be released to allow the tendons to glide freely. The tendons are sometimes covered with significant inflammatory tissue. If this is found it may be removed. The wounds are closed with dissolving stitches, and a waterproof plaster applied.

A simple wool and bandage dressing is applied to the wrist. Afterwards, the wrist is not splinted. Movement of the thumb is encouraged immediately and you can use your hands for most activities after the operation. It is advised not to get the wound wet until 10 days after the surgery.

In conclusion…

De Quervain’s synovitis is a common cause of pain on the side of the wrist. It is easily treatable, and if surgery is necessary, it is a minor procedure which can be performed under local anaesthetic.

Yours in good health,

Dr Warren Matthee

MB BCh (Wits), MRCS (England), MMed (Ortho Surg), FC Orth (SA)

Orthopaedic Surgeon

admin@drmatthee.com

(011) 304 6784

About the author…

I am an orthopaedic surgeon with a special interest in sports injuries and minimally invasive (arthroscopic) surgery of the knee and shoulder. I treat patients at Waterfall Hospital in Waterfall/Midrand and Morningside Mediclinic in Sandton. Besides these, I also treat patients from other areas as well, including Rosebank, Sunninghill and Fourways.

Get in Touch

Please use the form below to get in touch with Dr Matthee’s rooms.

The post De Quervain’s synovitis – a cause of wrist pain appeared first on Dr Warren Matthee.

What is a graft in ACL surgery?

An ACL graft is a substitute for the normal ACL in your knee. The ACL (anterior cruciate ligament) is one of the four major stabilising ligaments in the knee. It is commonly injured in sporting activities. The ACL does not heal very well, and an injury usually results in an unstable knee. This in turn can result in the development painful arthritis in later years. Surgery is usually recommended for an ACL tear, especially in younger people and those who are active (read: Do I need to have ACL surgery?).

Over the years, attempts have been made to try and repair the ACL once it has been torn. Unfortunately, the success rates for a repair are not good. The standard procedure performed by most surgeons, therefore, is to use a substitute tendon in your knee to replace the torn ACL. This substitute tendon is called the ACL graft.

The basic procedure of an ACL reconstruction is to remove parts or all the torn ACL and replace it with the ACL graft. Tunnels are created in the thigh bone (femur) and shin bone (tibia). The ACL graft is threaded into the middle of the joint and secured on the femur and tibia using fixatives such as metal buttons, screws, or staples.

Types of ACL graft

The most common grafts used in ACL surgery can be divided into three types, autograft, allograft, and synthetic grafts.

An autograft is a tendon which is taken from another location on your own body and used to make the new ACL. The site where the tendon is removed (harvested) is called the donor site. The term “donor site morbidity” is a term used to encompass any “negative factors” or possible complications associated with harvesting the tendon. This obviously includes the skin incision and resulting scar, but can also include infection, fracture and injury to blood vessels and nerves.

An allograft is the same type of tissue used in an autograft, but the difference is that it is obtained from another human donor.

A synthetic ACL graft is a manufactured cord or ribbon-like implant which is not made of human tissue.

I will briefly discuss the least common ACL graft choices first.

Synthetic ACL graft

The synthetic ACL graft appears to be attractive a first glance. This is because you do not have to remove any tissue from another area of the body. There are therefore no extra skin incisions, no risk of fracture, no graft harvest pain etc. (no donor site morbidity). They are extremely strong, and the marketing behind these products will have you believe that you may return to your sporting activity much quicker than with a tendon graft. This is especially attractive for professional and semi-professional athletes. Unfortunately, synthetic grafts have a high failure rate. If the graft fails, this means that you will have to have a revision procedure to restore stability to the knee.

Allograft

An allograft also appears to be an attractive option. The advantage of an allograft is that once again there is no donor site morbidity as the graft is not harvested from your own body. It is also possible to choose from a variety of tissues, including hamstring, patella, quadriceps and Achilles tendons.

The biggest problem with using an allograft relates to potential infection. Because of the high prevalence of HIV and other infectious diseases in South Africa, the graft must be treated before it can be used inside your body. This may include irradiation. This treatment can weaken the graft and result in high risk of failure. It is therefore not a great choice for an ACL graft in our country. They are, however, successfully used for other ligaments in the knee where failure rates are not as high. In countries where the risk of contracting an infectious disease from the graft is low, “fresh” allografts are used more frequently and successfully as they do not have to go undergo the same treatment before being used in your knee.

Autograft

The most common ACL graft choice in South Africa is therefore the autograft. This is a tendon which is taken from another area of your body. The three commonest harvest sites are the hamstring tendons, the quadriceps tendon, and the patellar tendon.

Hamstring ACL autograft

The hamstring tendons are the cord-like structures which you can feel on the back of your knee towards the inner side. To harvest them, a 2 or 3 cm incision must be made on the front of the upper end of the tibia. One or two of the hamstring tendons (semitendinosis and gracilis) are harvested from the leg which is undergoing the ACL reconstruction. These are then prepared to create the new ACL graft.

Patellar tendon (BTB) autograft

The patellar tendon is the strong tendon connecting the kneecap (patella) to the tibia in the front of your knee. A patellar tendon graft is also called a bone-patellar-tendon-bone graft or BTB graft. Harvesting of the graft involves an incision on the front of the knee, starting from the lower end of the patella.  A small bone plug is removed from the patella and the tibia along with a 1 cm strip of tendon in-between the two bone plugs for the ACL graft.

Quadriceps tendon autograft

The quadriceps tendon is the strong tendinous attachment of the quadriceps muscle. It attaches to the top part of the patella. Harvesting involves a skin incision on the front of the knee, starting from the upper end of the patella. A small bony plug from the top of the patella is removed along with a 1 cm strip of quadriceps tendon.

Hamstring, patellar and quadriceps tendons are usually harvested from the same leg which is undergoing the ACL reconstruction. They may also be harvested from the other leg if needed (e.g. in multi-ligament reconstructions and revision procedures).

A brief comparison of the autograft options

Of the three autograft options the hamstring tendon is the most popular graft choice in recent years in South Africa. It is a strong graft. Harvesting does not involve cutting into bone and therefore there is no risk of fracture.

The BTB or patellar tendon graft was the original ACL graft choice, and in some countries is still regarded as the gold standard. It is stiffer than the hamstring graft, but the strength of a hamstring graft is still stronger than your original ACL. The disadvantage of the patellar tendon graft is that it involves cutting into the bone and therefore fracture is a risk. There is also increased risk of developing anterior knee pain (pain in the front of the knee).

The quadriceps graft is probably the least widely used. There is also a risk of patella fracture in harvesting this graft although some surgeons use a quadriceps graft without a bone plug. There is said to be a lower risk of anterior knee pain.

So which ACL autograft is best?

Several studies have been performed to try and evaluate which graft is the best. As far as performance goes there is no clear winner with regard to long-term stability. There are no significant differences between the three autografts when comparing muscle strength, function, return to sports and patient satisfaction.

Which ACL graft should I choose?

The question remains, therefore, which ACL graft one should choose if having an ACL reconstruction? In my opinion the answer is that you should go with the graft that your surgeon recommends. Allow the surgeon to do what he or she does best. I would, however, be cautious if your surgeon recommends using an allograft or a synthetic graft in your knee for a primary (first time) ACL reconstruction. Many of the revision procedures that I have had to perform have resulted from previous use of a synthetic graft.

In conclusion…

A knee surgeon should be familiar with the harvesting and use of all the different types of ACL graft but many of us will have a preference and this includes myself. My preferred graft is the hamstring graft. I find it easy to harvest with a low rate of complications and good results. For a revision procedure my preference is to use the hamstring graft from the other leg although the option remains to use the quadriceps or patellar tendon graft from the same leg if the patient prefers this option.

Yours in good health,

Dr Warren Matthee

MB BCh (Wits), MRCS (England), MMed (Ortho Surg), FC Orth (SA)

Orthopaedic Surgeon

admin@drmatthee.com

(011) 304 6784

About the author…

I am an orthopaedic surgeon with a special interest in sports injuries and minimally invasive (arthroscopic) surgery of the knee and shoulder. I perform ACL reconstructions as well as general orthopaedic procedures at Waterfall Hospital in Waterfall/Midrand and Morningside Mediclinic in Sandton. Besides these, I also treat patients from other areas as well, including Rosebank, Sunninghill and Fourways.

Get in Touch

Please use the form below to get in touch with Dr Matthee’s rooms. A representative will respond to you shortly.

The post ACL graft options in ACL reconstruction – which one? appeared first on Dr Warren Matthee.